Update August 2008 No. 2008-135

Department of Health Services

Affected Programs: All Programs To: All Providers, HMOs and Other Managed Care Programs

ForwardHealth Announces the New Remittance Advice This ForwardHealth Update announces the Remittance Advice (RA), a new paper format for provider remittance information available after the October 2008 implementation of ForwardHealth interChange. Providers will be able to view the RA online through the ForwardHealth Portal in addition to receiving a paper copy. The RA gives providers important information regarding the processing of claims, adjustment requests, and other financial transactions. This Update explains the different sections of the RA and how to read remittance information.

Providers who participate in Wisconsin Medicaid, BadgerCare Plus, SeniorCare, Wisconsin Chronic Disease Program, and/or the Wisconsin Well Woman Program will receive the RA. The RA replaces the Remittance and Status Report.

The New Remittance Advice and the Implementation of ForwardHealth interChange

In October 2008, the Department of Health Services (DHS) will implement ForwardHealth interChange, which replaces Wisconsin’s existing Medicaid Management Information System (MMIS). ForwardHealth interChange will be supported as part of the State's new fiscal agent contract with EDS. With ForwardHealth interChange, providers and trading partners will have more ways to submit electronic claims, adjustments, and prior authorization (PA) requests through the secure ForwardHealth Portal and access the Remittance Advice (RA) through an account

on the Portal. Refer to the March 2008 ForwardHealth Update (2008-24), titled "Introducing ForwardHealth interChange, a New Web-Based Information System for State Health Care Programs," for an overview of the implementation and a more detailed outline of the many business process enhancements and added benefits the new system and fiscal agent contract will provide. This Update introduces an RA that is new to all providers, including Wisconsin Medicaid, BadgerCare Plus, SeniorCare, Wisconsin Chronic Disease Program (WCDP) and Wisconsin Well Woman Program (WWWP) providers. The new RA replaces the current Remittance and Status (R/S) Report and will be implemented with ForwardHealth interChange in October 2008. Remittance information will no longer be sent to providers on CDs or tapes with the implementation of ForwardHealth interChange. A future publication will include implementation dates related to the RA and the R/S Report. The format of the paper provider remittance information has been redesigned for the implementation of the ForwardHealth interChange system. The RA offers providers more detailed remittance information than the R/S Report, in a format that is easier to read and to search. Other advantages include: • The RA divides information about claims into

several designations, including the status of the claim (i.e., paid or adjusted) and the type of claim (i.e.,

ForwardHealth Provider Information August 2008 No. 2008-135 2

professional services or hospital services), for easy reference.

• The Summary section has been expanded and gives providers an overview of all claim and financial transactions for the current financial cycle, the month, and the year.

• The new RA will be available through the provider’s Portal account.

Overview of the Remittance Advice

The RA provides important information about the processing of claims and adjustment requests as well as additional financial transactions such as refunds or recoupment amounts withheld. Providers will receive an RA from the appropriate ForwardHealth program when they have at least one claim, adjustment request, or financial transaction processed. An RA is generated regardless of how a claim or adjustment is submitted (electronically or on paper).

Remittance Advice Generated by Payer and by Provider Certification

Providers may receive an RA from one or more of the following ForwardHealth financial payers: • Wisconsin Medicaid (Wisconsin Medicaid is the

financial payer for the Medicaid, BadgerCare Plus, and SeniorCare programs).

• Wisconsin Chronic Disease Program. • Wisconsin Well Woman Program. Note: Each of the three payers generate separate RAs for the claims, adjustment requests, or other financial transactions submitted to the payer. A provider who submits claims, adjustment requests, or other financial transactions to more than one of these payers may receive several RAs. The RA is generated per provider certification. Providers who have a single National Provider Identifier (NPI) that is used for multiple certifications should be aware that an RA will be generated for each certification, but the same NPI will be reported on each of the RAs.

For instance, a hospital has obtained a single NPI. The hospital has a clinic, a lab, and a pharmacy, that are all certified with ForwardHealth. The clinic, the lab, and the pharmacy submit separate claims that indicate the same NPI as the hospital. Separate RAs will be generated for the hospital, the clinic, the lab, and the pharmacy.

Remittance Advice Financial Cycles

Each financial payer (Medicaid, WCDP, and WWWP) has separate financial cycles that occur on different days of the week. The RAs are produced and mailed to providers after each financial cycle is completed. Therefore, providers might receive RAs from different payers on different days of the week. Certain financial transactions may run on a daily basis, including non-claim related payouts and stop payment reissues. Providers may receive the RAs generated by these financial transactions at any time during the week.

Obtaining the Remittance Advice

One paper copy of each RA will be mailed to the provider. Providers who receive the paper RA will also be able to access RAs through their secure Portal accounts at www.forwardhealth.wi.gov/. The main page of the secure Portal account will list the last 10 RAs issued to the provider. Providers should refer to the July 2008 Update (2008-94), titled “Introducing the ForwardHealth Portal,” and the July 2008 Update (2008-124), titled “Establishing a Provider Account on the ForwardHealth Portal,” for more information about the Portal and Portal accounts. Providers may choose to opt out of receiving a paper RA by sending a written request to the follow address:

ForwardHealth Provider Maintenance 6406 Bridge Rd Madison WI 53784-0006

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Note: Providers who do not receive a paper RA will not be able to view the RA on the Portal. Providers who opt out of receiving the paper RA should make sure they receive the electronic 835 Health Care Claim Payment/Advice (835) transaction. Providers may obtain additional paper copies of the RA by sending a written request to the following address:

ForwardHealth Written Correspondence 6406 Bridge Rd Madison WI 53784-0005

Providers may also call Provider Services at (800) 947-9627 to request additional paper copies of the RA.

Sections of the Remittance Advice

The RA includes the following sections: • Address page. • Banner Messages. • Paper Check, if applicable. • Claims processing information. • Explanation of Benefits (EOB) Code Descriptions. • Financial Transactions. • Service Code Descriptions. • Summary. Refer to Attachments 3-11 of this Update for samples of the RA sections. Each RA section is described in detail later in this Update.

Remittance Advice Header Information

The first page of each section of the RA (except the address page) displays the same RA header information. Refer to any of the sample RA sections in Attachments 3-11 to view the RA header. On the left-hand side of the header, providers will find the following fields:

• The technical name of the RA section (e.g., CRA-TRAN-R), which is an internal ForwardHealth designation.

• The RA number, which is a unique number assigned to each RA that is generated.

• The name of the payer (Medicaid, WCDP, or WWWP).

• The “Pay to” address of the provider. The “Pay to” address is used for mailing purposes.

In the middle of the header, providers will find the following information: • A description of the financial cycle. • The name of the RA section (e.g., “Financial

Transactions” or “Professional Services Claims Paid”).

The right-hand side of the header will report the following information: • The date of the financial cycle during which the RA

was generated. • The page number. • The “Payee ID” of the provider. A payee ID is

defined as the identification number of a unique entity receiving payment for goods and/or services from ForwardHealth. The payee ID is up to 15 characters long and may be based on a pre-existing identification number, such as the Medicaid provider number. The payee ID is an internal ForwardHealth designation. The Medicaid provider number will display in this field for providers who do not have an NPI.

• The NPI of the provider, if applicable. This field will be blank for those providers who do not have an NPI.

• The number of the check issued for the RA, if applicable.

• The date of payment on the check, if applicable.

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Remittance Advice Sections Related to Claims Processing

Overview

The claims processing sections of the RA include information submitted on claims and the status of the claims. The four claim status designations are paid, adjusted, denied, or in process (for WWWP providers only). The RA also supplies information about why the claim was adjusted or denied or how the reimbursement was calculated for the payment. The claims processing information in the RA is grouped by the type of claim and the status of the claim. Providers will receive claims processing sections that correspond to the types of claims that have been finalized during the current financial cycle. The claims processing sections will reflect the types of claims submitted, such as the following: • Compound drug claims. • Dental claims. • Drug claims. • Inpatient claims. • Long term care claims. • Medicare crossover institutional claims. • Medicare crossover professional claims. • Outpatient claims. • Professional claims. Attachment 1 lists the claim types found on the RA and the provider types who may receive these sections on RAs. The claims processing sections will be divided into the following status designations: • Adjusted claims. • Denied claims. • In process claims (for WWWP outpatient and

professional claims only). • Paid claims.

Attachments 3-6 are sample formats for professional services claim processing sections of the RA.

Identifying the Claims Reported on the Remittance Advice

The RA will report the first 12 characters of the Medical Record Number (MRN) and/or a Patient Control Number (PCN), also referred to as Patient Account Number, submitted on the original claims. The MRN and PCN fields are located beneath the member’s name on any section of the RA that reports claims processing information. Providers are strongly encouraged to enter these numbers on claims. Entering the MRN and/or the PCN on claims may assist providers in identifying the claims reported on the RA. Note: Claims processing sections for dental and drug claims do not include the MRN or the PCN.

Member Identification Numbers

The member’s name and 10-digit member identification number will always appear in the claims processing sections of the RA. Medicaid, BadgerCare Plus, SeniorCare, WCDP, and WWWP members will receive new member IDs when the interChange system is implemented. The RA will report new member IDs even though ForwardHealth will accept old member IDs on submitted claims.

Claim Number

Each claim or adjustment request received by ForwardHealth is assigned a unique claim number (also known as the internal control number [ICN]). However, denied claims that were submitted using the National Council for Prescription Drug Programs 5.1 Telecommunication Standard for Retail Pharmacy Claims (NCPDP 5.1) transaction are not assigned an ICN.

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The ICN consists of 13 digits that identify valuable information (e.g., the date the claim was received by ForwardHealth, how the claim was submitted) about the claim or adjustment request. Refer to Attachment 2 of this Update for information about interpreting claim numbers.

Prior Authorization Number

The RA reports PA numbers used to process the claim. Prior authorization numbers appear in the detail lines of claims processing information.

Explanation of Benefit Codes in the Claim Header and in the Detail Lines

Explanation of Benefits (EOB) codes are four-digit numeric codes specific to ForwardHealth that correspond to a printed message about the status or action taken on a claim, claim detail, adjustment, or adjustment detail. The claim processing sections of the RA report EOBs for the claim header information and for the detail lines, as appropriate. Header information is a summary of the information from the claim, such as the dates of service that the claim covers or the total amount paid for the claim. Detail lines report information from the claim details, such as specific procedure codes or revenue codes, the amount billed for each code, and the amount paid for a detail line item. Header EOBs are listed below the claim header information and pertain only to the header information. Detail line EOBs are listed after each detail line and pertain only to the detail line.

Claims Adjusted Section

Providers will receive this section if any of their claims were adjusted during the current financial cycle. A claim may be adjusted because one of the following occurred: • An adjustment request was submitted by the

provider. • ForwardHealth initiated an adjustment.

• A cash refund was submitted to ForwardHealth. In an adjusted claims section, providers will see the original claim information in the claim header surrounded by parentheses. Information about the adjusted claim appears directly below the original claim header information. Providers should check the Adjustment EOB for a summary of why the claim was adjusted; other header EOBs will provide additional information. The adjusted claims section lists detail lines only for the adjusted claim with detail line EOBs. Details from the original claim will not be reported on the adjusted claims sections of the RA. Note: For adjusted drug claims, only the compound drug sections include detail lines. Below the claim header and the detail information, providers will see one of three possible responses with a corresponding dollar amount: “additional payment,” “overpayment to be withheld,” or “refund amount applied.” An amount will appear for “additional payment” if ForwardHealth owes additional monies to the provider after the claim has been adjusted. This amount will be added to the provider’s total reimbursable amount for the RA. An amount will appear for “overpayment to be withheld” if ForwardHealth determines, as the result of an adjustment to the original claim, that the provider owes ForwardHealth monies. ForwardHealth will automatically withhold this amount from payments made to the provider during the same financial cycle or during subsequent financial cycles, if necessary. This amount will also appear in the Financial Transactions section as an outstanding balance under “Accounts Receivable.”

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An amount will appear for “refund amount applied” if ForwardHealth makes a payment to refund a cash receipt to a provider. See Attachment 3 for a sample Professional Services Claims Adjusted section.

Submitting Cash Refunds as Adjustments

With the exception of nursing home and hospital providers, providers may return an overpayment to ForwardHealth with a cash refund. Nursing home and hospital providers routinely receive retroactive rate adjustments, requiring previously paid claims to be reprocessed to reflect a new rate. This is not possible after a cash refund is done. When submitting a personal check to ForwardHealth for an overpayment, providers should include a copy of the RA for the claim to be adjusted and highlight the affected claim on the RA. If a copy of the RA is not available, providers should indicate the ICN, the NPI (if applicable), and the payee ID from the RA for the claim to be adjusted. The check should be sent to the following address:

ForwardHealth Financial Services Cash Unit 6406 Bridge Rd Madison WI 53784-0004

Note: The Claim Refund Form, HCF 13066, will be discontinued with implementation of ForwardHealth interChange. Providers should not submit this form after implementation. Provider should follow the instructions detailed above to submit a claim refund.

Claims Denied Section

Providers will receive this section if any of their claims were denied during the current financial cycle. In a denied claims section, providers will see the original claim header information reported along with EOBs for the claim header and the detail lines, as applicable.

Providers should refer to the EOB Code Description section of the RA to determine why the claim was denied. See Attachment 4 for a sample Professional Services Claims Denied section.

Claims in Process Section

Wisconsin Well Woman Program providers will receive this section if any of their outpatient or professional claims are still processing during the current financial cycle. This section is informational only. No action should be taken on a claim that is in process. See Attachment 5 for a sample Professional Services Claims in Process section.

Claims Paid Section

Providers will receive this section if any of their claims were determined payable during the current financial cycle. In a paid claims section, providers will see the original claim information reported along with EOBs for both the header and the detail lines, if applicable. Providers should refer to the EOB Code Description section of the RA for more information about how the reimbursement amount was determined. See Attachment 6 for a sample Professional Services Claims Paid section.

Cutback Fields on the Remittance Advice for Adjusted and Paid Claims

Cutback fields indicate amounts that reduce the allowed amount of the claim. Examples of cutbacks include other insurance, member copayment, spenddown amounts, deductibles, or patient liability amounts. Amounts indicated in a cutback field are subtracted from the total allowed reimbursement.

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Providers should note that cutback amounts indicated in the header of an adjusted or paid claim section apply only to the header. Not all cutback fields that apply to a detail line (such as copayments or spenddowns) will be indicated on the RA; the detail line EOBs inform providers that an amount was deducted from the total reimbursement but may not indicate the exact amount. Note: Providers who receive 835 transactions will be able to see all deducted amounts on paid and adjusted claims.

Calculating Totals on the Remittance Advice for Adjusted and Paid Claims

The total amounts for all adjusted or paid claims reported on the RA appear at the end of the adjusted claims and paid claims sections. ForwardHealth calculates the total by adding the amounts for all of the claims; cutback amounts are subtracted from the allowed amount to reach the total reimbursement for the claims. Note: Some cutbacks that are reported in detail lines will appear as EOB codes and will not display an exact dollar amount.

Other Sections of the Remittance Advice

Address Page

The Address page displays the provider name and “Pay to” address of the provider for purposes of mailing the paper RA. Future publications will include more information about maintaining addresses with ForwardHealth.

Banner Messages

The Banner Messages section of the RA contains important, time-sensitive messages for providers. For example, banner messages might inform providers of claim adjustments initiated by ForwardHealth, claim submission deadlines, and dates of upcoming training sessions. It is possible for each RA to include different

messages, so providers who receive multiple RAs should read all of their banner messages. Attachment 7 is a sample format for the Banner Messages section.

EOB Code Descriptions

The EOB Code Descriptions section lists all EOB codes reported on the RA with corresponding descriptions. Attachment 8 is a sample format for the EOB Code Descriptions section.

Financial Transactions Page

The Financial Transactions section details the provider’s weekly financial activity. Financial transactions reported on the RA include payouts, refunds, accounts receivable, and payments for claims. Payouts are payments made to the provider by ForwardHealth that do not correspond to a specific claim (i.e., nursing home assessment reimbursement). Refunds are payments made to providers for overpayments. The Accounts Receivable section displays the accounts receivable for amounts owed by providers. The accounts receivable is set to automatically recover any outstanding balance so that money owed is automatically recouped from the provider. If the full amount cannot be recouped during the current financial cycle, an outstanding balance will appear under “Accounts Receivable.” The “Total Recoupment” field lists the cumulative amount recovered for the accounts receivable. Every financial transaction that results in the creation of an accounts receivable is assigned an identification number called the “adjustment ICN.” The adjustment ICN for an adjusted claim matches the original ICN assigned to the adjusted claim. For other financial

ForwardHealth Provider Information August 2008 No. 2008-135 8

transactions, the adjustment ICN is determined by the following formula.

Type of Character and Description

Applicable Characters and

Description

Transaction — The

first character indicates

the type of financial

transaction that created

the accounts receivable.

V — Capitation

adjustment

1 — OBRA Level 1

screening void request

2 — OBRA Nurse Aide

Training/Testing void

request

Identifier — Ten

additional numbers are

assigned to complete

the Adjustment ICN.

The identifier is used

internally by

ForwardHealth.

Attachment 9 is a sample format for the Financial Transactions section.

Service Code Descriptions

The Service Code Descriptions section lists all the service codes (i.e. procedure codes or revenue codes) reported on the RA with their corresponding descriptions. Attachment 10 is a sample format for the Service Code Descriptions section.

Summary

The Summary section reviews the provider’s claim activity and financial transactions with the payer (Medicaid, WCDP, or WWWP) for the current financial cycle, the month-to-date, and the year-to-date, if applicable. Under the “Claims Data” heading, providers can review the total number of claims that have been paid, adjusted, or denied along with the total amount reimbursed for all paid and adjusted claims. Only WWWP providers will see amounts reported for “Claims in Process.” Other providers will always see zeroes in these fields.

Under the “Earnings Data” heading, providers will see total reimbursement amounts for other financial transactions, such as reimbursement for Omnibus Budget Reconciliation Act of 1987 (OBRA) Level 1 screening, reimbursement for OBRA Nurse Aid Training/Testing, and capitation payments. Note: HMOs should note that capitation payments are only reported in the Summary section of the RA. HMOs will continue to receive supplemental reports of their financial transactions from ForwardHealth. The “Earnings Data” portion also summarizes refunds and voids and reports the net payment for the current financial cycle, the month-to-date, and the year-to-date, if applicable. Providers should note that the Summary section will include outstanding checks 90 days after issuance and/or payments made to lien holders, if applicable. Attachment 11 is a sample format for the Summary section.

For More Information

Providers who have questions about an RA received after ForwardHealth implementation should call Provider Services at (800) 947-9627.

The ForwardHealth Update is the first source of program policy and billing information for providers. Wisconsin Medicaid, BadgerCare Plus, SeniorCare, and Wisconsin Chronic Disease Program are administered by the Division of Health Care Access and Accountability, Wisconsin Department of Health Services (DHS). Wisconsin Well Woman Program is administered by the Division of Public Health, Wisconsin DHS. For questions, call Provider Services at (800) 947-9627 or visit our Web site at dhs.wisconsin.gov/forwardhealth/.

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ForwardHealth Provider Information August 2008 No. 2008-135 9

ATTACHMENT 1 Claim Types on the Remittance Advice and

Corresponding Provider Types The following table lists the claim types that may be reported on the ForwardHealth Remittance Advice (RA) and the provider types that correspond to each claim type, including Wisconsin Chronic Disease Program (WCDP) and Wisconsin Well Woman Program (WWWP) providers.

Claim Types Provider Types

Dental claims Dentists, dental hygienists, HealthCheck agencies that provide dental

services.

Drug and compound drug claims Pharmacies and dispensing physicians.

Inpatient claims Inpatient hospital providers and institutes for mental disease providers.

Long term care claims Nursing homes.

Medicare crossover institutional claims Most providers who submit claims on the UB-04.

Medicare crossover professional claims Most providers who submit claims on the 1500 Health Insurance Claim

Form.

Outpatient claims Outpatient hospital providers and hospice providers.

Professional claims Ambulance providers, ambulatory surgery centers, anesthesiologist

assistants, audiologists, case management providers, certified registered

nurse anesthetists, chiropractors, community care organizations,

community support programs, crisis intervention providers, day treatment

providers, family planning clinics, federally qualified health centers,

HealthCheck providers, HealthCheck “Other Services” providers,

hearing instrument specialists, home health agencies, independent labs,

individual medical supply providers, medical equipment vendors, mental

health/substance abuse clinics, nurses in independent practice, nurse

practitioners, occupational therapists, opticians, optometrists, personal

care agencies, physical therapists, physician assistants, physician clinics,

physicians, podiatrists, portable X-ray providers, prenatal care

coordination providers, psychologists, rehabilitation agencies, respiratory

therapists, rural health clinics, school-based services providers,

specialized medical vehicle providers, speech and hearing clinics,

speech-language pathologists, therapy groups.

ForwardHealth Provider Information August 2008 No. 2008-135 10

ATTACHMENT 2 Interpreting Claim Numbers

Each claim and adjustment received by ForwardHealth is assigned a unique claim number (also known as the internal control number or ICN). This number identifies valuable information about the claim and adjustment request. The following diagram and table provide detailed information about interpreting the claim number.

Type of Number and Description Applicable Numbers and Description

Region — Two digits indicate the region. The region

indicates how ForwardHealth received the claim or

adjustment request.

10 — Paper Claims with No Attachments

11 — Paper Claims with Attachments

20 — Electronic Claims with No Attachments

21 — Electronic Claims with Attachments

22 — Internet Claims with No Attachments

23 — Internet Claims with Attachments

25 — Point-of-Service Claims

26 — Point-of-Service Claims with Attachments

40 — Claims Converted from Former Processing System

45 — Adjustments Converted from Former Processing

System

50–59 — Adjustments

80 — Claim Resubmissions

90–91 — Claims Requiring Special Handling

Year — Two digits indicate the year ForwardHealth

received the claim or adjustment request.

For example, the year 2008 would appear as 08.

Julian date — Three digits indicate the day of the

year, by Julian date, that ForwardHealth received the

claim or adjustment request.

For example, February 3 would appear as 034.

Batch range — Three digits indicate the batch range

assigned to the claim.

The batch range is used internally by ForwardHealth.

Sequence number — Three digits indicate the

sequence number assigned within the batch range.

The sequence number is used internally by ForwardHealth.

ForwardHealth Provider Information August 2008 No. 2008-135 11

ATTACHMENT 3 Sample Professional Services Claims Adjusted Section of the

Remittance Advice Remittance Advice — Professional Service Claim Adjustments Sample REPORT: CRA-HCAD-R FORWARDHEALTH INTERCHANGE DATE: MM/DD/CCYY RA#: 999999999 <Financial Cycle Description> PAGE: 9,999 PAYER: XXXX PROVIDER REMITTANCE ADVICE PROFESSIONAL SERVICE CLAIM ADJUSTMENTS XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX PAYEE ID 999999999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX NPI 9999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CHECK/EFT NUMBER 999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, XX XXXXX-XXXX PAYMENT DATE MM/DD/CCYY --ICN-- PCN MRN SERVICE DATES BILLED AMT OTH INS AMT COPAY AMT PAID AMT FROM TO ALLOWED AMT SPENDDOWN AMT CO-INS CB OUTPAT DED MEMBER NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX MEMBER NO.: XXXXXXXXXXXX RRYYJJJBBBSSS XXXXXXXXXXXX XXXXXXXXXXXX MMDDYY MMDDYY (9,999,999.99) (9,999,999.99) (999,999.99) (9,999,999.99) (9,999,999.99) (999,999.99) (999,999.99) (999,999.99) RRYYJJJBBBSSS XXXXXXXXXXXX XXXXXXXXXXXX MMDDYY MMDDYY 9,999,999.99 9,999,999.99 999,999.99 9,999,999.99 9,999,999.99 999,999.99 999,999.99 999,999.99 ADJUSTMENT EOB: 9999 HEADER EOBS: 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 SERVICE DATES ALLW UNITS RENDERING PROVIDER PA NUMBER PROC CD MODIFERS FROM TO COPAY AMT BILLED AMT ALLOWED AMT PAID AMT DETAIL EOBS XXXXX XX XX XX XX MMDDYY MMDDYY 9999.99 XXX XXXXXXXXXXXXXXX XXXXXXXXXX 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 999,999.99 9,999,999.99 9,999,999.99 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 XXXXX XX XX XX XX MMDDYY MMDDYY 9999.99 XXX XXXXXXXXXXXXXXX XXXXXXXXXX 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 999,999.99 9,999,999.99 9,999,999.99 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 XXXXX XX XX XX XX MMDDYY MMDDYY 9999.99 XXX XXXXXXXXXXXXXXX XXXXXXXXXX 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 999,999.99 9,999,999.99 9,999,999.99 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 XXXXX XX XX XX XX MMDDYY MMDDYY 9999.99 XXX XXXXXXXXXXXXXXX XXXXXXXXXX 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 999,999.99 9,999,999.99 9,999,999.99 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 ADDITIONAL PAYMENT 9,999,999.99 OVERPAYMENT TO BE WITHHELD 9,999,999.99 REFUND AMOUNT APPLIED 9,999,999.99 TOTAL PROFESSIONAL SERVICE CLAIMS ADJ: 99,999,999.99 99,999,999.99 9,999,999.99 99,999,999.99 99,999,999.99 9,999,999.99 9,999,999.99 9,999,999.99 TOTAL NO. ADJ: 999,999

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ATTACHMENT 4 Sample Professional Services Claims Denied Section of the

Remittance Advice Remittance Advice — Professional Service Claims Denied Sample REPORT: CRA-HCDN-R FORWARDHEALTH INTERCHANGE DATE: MM/DD/CCYY RA#: 999999999 <Financial Cycle Description> PAGE: 9,999 PAYER: XXXX PROVIDER REMITTANCE ADVICE PROFESSIONAL SERVICE CLAIMS DENIED XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX PAYEE ID 999999999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX NPI 9999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CHECK/EFT NUMBER 999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, XX XXXXX-XXXX PAYMENT DATE MM/DD/CCYY

--ICN-- PCN MRN SERVICE DATES BILLED OTH INS SPENDDOWN FROM TO AMOUNT AMOUNT AMOUNT MEMBER NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX MEMBER NO.: XXXXXXXXXXXX RRYYJJJBBBSSS XXXXXXXXXXXX XXXXXXXXXXXX MMDDYY MMDDYY 999,999,999.99 9,999,999.99 999,999.99 HEADER EOBS: 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999

SERVICE DATES PA NUMBER PROC CD MODIFIERS ALLW UNITS FROM TO RENDERING PROVIDER BILLED AMT DETAIL EOBS XXXXX XX XX XX XX 9999.99 MMDDYY MMDDYY XXX XXXXXXXXXXXXXXX XXXXXXXXXX 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 XXXXX XX XX XX XX 9999.99 MMDDYY MMDDYY XXX XXXXXXXXXXXXXXX XXXXXXXXXX 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 XXXXX XX XX XX XX 9999.99 MMDDYY MMDDYY XXX XXXXXXXXXXXXXXX XXXXXXXXXX 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 XXXXX XX XX XX XX 9999.99 MMDDYY MMDDYY XXX XXXXXXXXXXXXXXX XXXXXXXXXX 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999

TOTAL PROFESSIONAL SERVICE CLAIMS DENIED: 9,999,999,999.99 99,999,999.99 9,999,999.99 TOTAL NO. DENIED: 999,999

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ATTACHMENT 5 Sample Professional Services Claims in Process Section of the

Remittance Advice Remittance Advice — Professional Service Claims In Process Sample REPORT: CRA-HCSU-R FORWARDHEALTH INTERCHANGE DATE: MM/DD/CCYY RA#: 999999999 <Financial Cycle Description> PAGE: 9,999 PAYER: XXXX PROVIDER REMITTANCE ADVICE PROFESSIONAL SERVICE CLAIMS IN PROCESS XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX PAYEE ID 999999999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX NPI 9999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CHECK/EFT NUMBER 999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, XX XXXXX-XXXX PAYMENT DATE MM/DD/CCYY --ICN-- PCN MRN SERVICE DATES BILLED OTH INS FROM TO AMOUNT AMOUNT MEMBER NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX MEMBER NO.: XXXXXXXXXXXX RRYYJJJBBBSSS XXXXXXXXXXXX XXXXXXXXXXXX MMDDYY MMDDYY 9,999,999.99 9,999,999.99 HEADER EOBS: 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 SERVICE DATES ALLW RENDERING BILLED PROC CD MODIFIERS FROM TO UNITS PROVIDER AMOUNT DETAIL EOBS XXXXX XX XX XX XX MMDDYY MMDDYY 9999.99 XXX XXXXXXXXXXXXXXX 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 XXXXX XX XX XX XX MMDDYY MMDDYY 9999.99 XXX XXXXXXXXXXXXXXX 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 XXXXX XX XX XX XX MMDDYY MMDDYY 9999.99 XXX XXXXXXXXXXXXXXX 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 XXXXX XX XX XX XX MMDDYY MMDDYY 9999.99 XXX XXXXXXXXXXXXXXX 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 TOTAL PROFESSIONAL SERVICE CLAIMS IN PROCESS: 99,999,999.99 99,999,999.99 TOTAL NO. IN PROCESS: 999,999

ForwardHealth Provider Information August 2008 No. 2008-135 14

ATTACHMENT 6 Sample Professional Services Claims Paid Section of the

Remittance Advice Remittance Advice — Professional Service Claims Paid Sample REPORT: CRA-HCPD-R FORWARDHEALTH INTERCHANGE DATE: MM/DD/CCYY RA#: 999999999 <Financial Cycle Description> PAGE: 9,999 PAYER: XXXX PROVIDER REMITTANCE ADVICE PROFESSIONAL SERVICE CLAIMS PAID XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX PAYEE ID 999999999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX NPI 9999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CHECK/EFT NUMBER 999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, XX XXXXX-XXXX PAYMENT DATE MM/DD/CCYY --ICN-- PCN MRN SERVICE DATES BILLED AMT OTH INS AMT COPAY AMT PAID AMT FROM TO ALLOWED AMT SPENDDOWN AMT CO-INS CB OUTPAT DED MEMBER NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX MEMBER NO.: XXXXXXXXXXXX RRYYJJJBBBSSS XXXXXXXXXXXX XXXXXXXXXXXX MMDDYY MMDDYY 9,999,999.99 9,999,999.99 999,999.99 9,999,999.99 9,999,999.99 999,999.99 999,999.99 999,999.99 HEADER EOBS: 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 SERVICE DATES ALLW UNITS RENDERING PROVIDER PA NUMBER PROC CD MODIFIERS FROM TO COPAY AMT BILLED AMT ALLOWED AMT PAID AMT DETAIL EOBS XXXXX XX XX XX XX MMDDYY MMDDYY 9999.99 XXX XXXXXXXXXXXXXXX XXXXXXXXXX 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 999,999.99 9,999,999.99 9,999,999.99 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 XXXXX XX XX XX XX MMDDYY MMDDYY 9999.99 XXX XXXXXXXXXXXXXXX XXXXXXXXXX 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 999,999.99 9,999,999.99 9,999,999.99 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 XXXXX XX XX XX XX MMDDYY MMDDYY 9999.99 XXX XXXXXXXXXXXXXXX XXXXXXXXXX 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 999,999.99 9,999,999.99 9,999,999.99 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 XXXXX XX XX XX XX MMDDYY MMDDYY 9999.99 XXX XXXXXXXXXXXXXXX XXXXXXXXXX 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 999,999.99 9,999,999.99 9,999,999.99 9,999,999.99 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 TOTAL PROFESSIONAL SERVICE CLAIMS PAID: 99,999,999.99 99,999,999.99 9,999,999.99 99,999,999.99 99,999,999.99 9,999,999.99 9,999,999.99 9,999,999.99 TOTAL NO. PAID: 999,999

ForwardHealth Provider Information August 2008 No. 2008-135 15

ATTACHMENT 7 Sample Banner Messages Section of the Remittance Advice

Remittance Advice — Banner Messages Sample REPORT: CRA-BANN-R FORWARDHEALTH INTERCHANGE DATE: MM/DD/CCYY RA#: 999999999 <Financial Cycle Description> PAGE: 9,999 PAYER: XXXX PROVIDER REMITTANCE ADVICE BANNER MESSAGES XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX PAYEE ID 999999999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX NPI 9999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CHECK/EFT NUMBER 999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, XX XXXXX-XXXX PAYMENT DATE MM/DD/CCYY SUBJECT: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

ForwardHealth Provider Information August 2008 No. 2008-135 16

ATTACHMENT 8 Sample Explanation of Benefit (EOB) Code Descriptions Section of

the Remittance Advice Remittance Advice — EOB Code Descriptions Sample REPORT: CRA-EOBM-R FORWARDHEALTH INTERCHANGE DATE: MM/DD/CCYY RA#: 999999999 <Financial Cycle Description> PAGE: 9,999 PAYER: XXXX PROVIDER REMITTANCE ADVICE EOB CODE DESCRIPTIONS XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX PAYEE ID 999999999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX NPI 9999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CHECK/EFT NUMBER 999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, XX XXXXX-XXXX PAYMENT DATE MM/DD/CCYY EOB CODE DESCRIPTION 9999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

ForwardHealth Provider Information August 2008 No. 2008-135 17

ATTACHMENT 9 Sample Financial Transactions Section of the Remittance Advice

Remittance Advice — Financial Transactions Sample REPORT: CRA-TRAN-R FORWARDHEALTH INTERCHANGE DATE: MM/DD/CCYY RA#: 999999999 <Financial Cycle Description> PAGE: 9,999 PAYER: XXXX PROVIDER REMITTANCE ADVICE FINANCIAL TRANSACTIONS XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX PAYEE ID 999999999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX NPI 9999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CHECK/EFT NUMBER 999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, XX XXXXX-XXXX PAYMENT DATE MM/DD/CCYY ---------------NON-CLAIM SPECIFIC PAYOUTS TO PAYEE--------------- TRANSACTION PAYOUT REASON SERVICE DATE NUMBER AMOUNT CODE FROM THRU 99999999999 9,999,999.99 9999 MMDDYY MMDDYY 99999999999 9,999,999.99 9999 MMDDYY MMDDYY 99999999999 9,999,999.99 9999 MMDDYY MMDDYY 99999999999 9,999,999.99 9999 MMDDYY MMDDYY 99999999999 9,999,999.99 9999 MMDDYY MMDDYY 99999999999 9,999,999.99 9999 MMDDYY MMDDYY TOTAL PAYOUTS: 99,999,999.99 --------------NON-CLAIM SPECIFIC REFUNDS FROM PAYEE-------------- TRANSACTION REFUND REASON CHECK/EFT RECEIPT NUMBER AMOUNT CODE NUMBER DATE 99999999999 9,999,999.99 9999 999999999 MMDDYY 99999999999 9,999,999.99 9999 999999999 MMDDYY 99999999999 9,999,999.99 9999 999999999 MMDDYY 99999999999 9,999,999.99 9999 999999999 MMDDYY 99999999999 9,999,999.99 9999 999999999 MMDDYY 99999999999 9,999,999.99 9999 999999999 MMDDYY 99999999999 9,999,999.99 9999 999999999 MMDDYY 99999999999 9,999,999.99 9999 999999999 MMDDYY TOTAL REFUNDS: 99,999,999.99

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Remittance Advice — Financial Transactions Sample, Continued -----------------------ACCOUNTS RECEIVABLE----------------------- SETUP ORIGINAL RECOUPMENT REASON ADJUSTMENT A/R NUMBER DATE AMOUNT AMOUNT BALANCE CODE --ICN-- XXXXXXXXXXXXX MMDDYY 9,999,999.99 9,999,999.99 9,999,999.99 9999 XXXXXXXXXXXXX XXXXXXXXXXXXX MMDDYY 9,999,999.99 9,999,999.99 9,999,999.99 9999 XXXXXXXXXXXXX XXXXXXXXXXXXX MMDDYY 9,999,999.99 9,999,999.99 9,999,999.99 9999 XXXXXXXXXXXXX XXXXXXXXXXXXX MMDDYY 9,999,999.99 9,999,999.99 9,999,999.99 9999 XXXXXXXXXXXXX XXXXXXXXXXXXX MMDDYY 9,999,999.99 9,999,999.99 9,999,999.99 9999 XXXXXXXXXXXXX XXXXXXXXXXXXX MMDDYY 9,999,999.99 9,999,999.99 9,999,999.99 9999 XXXXXXXXXXXXX XXXXXXXXXXXXX MMDDYY 9,999,999.99 9,999,999.99 9,999,999.99 9999 XXXXXXXXXXXXX TOTAL RECOUPMENT 99,999,999.99

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ATTACHMENT 10 Sample Service Code Descriptions Section of the Remittance Advice

Remittance Advice — Service Code Descriptions Sample REPORT: CRA-DESC-R FORWARDHEALTH INTERCHANGE DATE: MM/DD/CCYY RA#: 999999999 <Financial Cycle Description> PAGE: 9,999 PAYER: XXXX PROVIDER REMITTANCE ADVICE SERVICE CODE DESCRIPTIONS XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX PAYEE ID 999999999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX NPI 9999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CHECK/EFT NUMBER 999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, XX XXXXX-XXXX PAYMENT DATE MM/DD/CCYY SVC CODE DESCRIPTION XXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

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ATTACHMENT 11 Sample Summary Section of the Remittance Advice

Remittance Advice — Summary Sample REPORT: CRA-SUMM-R FORWARDHEALTH INTERCHANGE DATE: MM/DD/CCYY RA#: 999999999 <Financial Cycle Description> PAGE: 9,999 PAYER: XXXX PROVIDER REMITTANCE ADVICE SUMMARY XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX PAYEE ID 999999999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX NPI 9999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CHECK/EFT NUMBER 999999999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, XX XXXXX-XXXX PAYMENT DATE MM/DD/CCYY -------------------------------------------CLAIMS DATA------------------------------------------- CURRENT CURRENT MONTH-TO-DATE MONTH-TO-DATE YEAR-TO-DATE YEAR-TO-DATE NUMBER AMOUNT NUMBER AMOUNT NUMBER AMOUNT CLAIMS PAID 999,999 99,999,999.99 9,999,999 999,999,999.99 9,999,999 999,999,999.99 CLAIM ADJUSTMENTS 999,999 99,999,999.99 9,999,999 999,999,999.99 9,999,999 999,999,999.99 TOTAL CLAIMS PAYMENTS 999,999 99,999,999.99 9,999,999 999,999,999.99 9,999,999 999,999,999.99

CLAIMS DENIED 999,999 9,999,999 9,999,999 CLAIMS IN PROCESS† 999,999 99,999,999.99 ------------------------------------------EARNINGS DATA------------------------------------------ PAYMENTS: CLAIMS PAYMENTS 99,999,999.99 999,999,999.99 999,999,999.99 CAPITATION PAYMENT 99,999,999.99 999,999,999.99 999,999,999.99 NURSE AID REIMBURSEMENTS 99,999,999.99 999,999,999.99 999,999,999.99 LEVEL ONE REIMBURSEMENTS 99,999,999.99 999,999,999.99 999,999,999.99 PAYOUTS 99,999,999.99 999,999,999.99 999,999,999.99 ACCOUNTS RECEIVABLE: CLAIM SPECIFIC: CURRENT CYCLE (99,999,999.99) (999,999,999.99) (999,999,999.99) OUTSTANDING FROM PREVIOUS CYCLES (99,999,999.99) (999,999,999.99) (999,999,999.99) NON-CLAIM SPECIFIC (99,999,999.99) (999,999,999.99) (999,999,999.99)

REFUNDS:

CLAIM SPECIFIC ADJUSTMENT REFUNDS (99,999,999.99) (999,999,999.99) (999,999,999.99) NON CLAIM SPECIFIC REFUNDS (99,999,999.99) (999,999,999.99) (999,999,999.99) OTHER FINANCIAL: VOIDS (99,999,999.99) (999,999,999.99) (999,999,999.99) NET PAYMENT** 99,999,999.99 999,999,999.99 999,999,999.99 NET EARNINGS 99,999,999.99 999,999,999.99 999,999,999.99

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Remittance Advice — Summary Sample, Continued ----------------------------------------OUTSTANDING CHECKS---------------------------------------- CHECK NUMBER ISSUE DATE ISSUE AMOUNT 999999999 MM/DD/CCYY 99,999,999.99 999999999 MM/DD/CCYY 99,999,999.99 999999999 MM/DD/CCYY 99,999,999.99 THE CHECK NUMBERS LISTED REMAIN OUTSTANDING. PLEASE CASH THE CHECK(S), OR CONTACT PROVIDER SERVICES IF THERE IS A PROBLEM.

** NET PAYMENT AMOUNT HAS BEEN REDUCED. LIEN PAYMENTS HAVE BEEN MADE TO THE FOLLOWING LIEN HOLDERS:

-----------------------------------PAYMENTS TO LIEN HOLDERS-------------------------------------- LIEN HOLDER NAME LIEN AMOUNT XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9,999,999.99 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9,999,999.99 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9,999,999.99 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9,999,999.99 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9,999,999.99 † THIS AMOUNT REPRESENTS THE BILLED AMOUNT.